A hundred years ago, physicians were generalists, treating most medical conditions. Humanity didn’t have nearly as much medical knowledge and knowhow back then so that for the most part a single doctor could master what was known. That has changed.
Medical knowledge now far exceeds a single expert’s ability to master it. Medical students receive a general training and then they specialize, seeking to learn just one small piece of what we know about medicine.
Specialists have become essential because of the complexity of care. The more we learn, the more kinds of specialists are needed. Increasingly, however, it is necessary to have patients see multiple specialists for a single problem, which causes fragmentation and delays the necessary care. Furthermore—and critically—the interplay between multiple causes of a single condition, or multiple aspects of its treatment, makes it difficult for the separated specialists to address such complex problems.
What is the solution?
A human being is a single working system and specialists must be able to work together as an integrated unit for diagnosis and treatment. Specially constituted teams of physicians and other care providers who work together on a regular basis should address the more complex problems. The cost of having such a team in place might seem high, but for complex cases such a team will prove to be more effective and less costly than the alternative—the difficulties, delays, and costs inherent in multiple appointments. The challenge is making sure the teams can work together smoothly and efficiently, and with better results than specialists working separately.
A well-integrated team of specialist physicians can be thought of as a "superdoctor." In order for medical teams to be superdoctors, they must get to know each other’s strengths and styles and act together seamlessly. Well-integrated teams have the combined specialized knowledge of each member and more: they have the ability to relate these different domains of knowledge and combine them in new ways. Moreover, they can act rapidly with this combined knowledge. They can be an important part of the solution to the problems of fragmentation.
Such teams have become standard practice in cancer care, where specialists in imaging, surgery, radiation therapy, and chemotherapy often meet and work together to treat patients. The wide diversity of cancers and of individual responses to treatment make the team approach necessary for effective care. These teams generally also include non-physician practitioners. While the team approach is most widely used for cancer, some medical centers, recognizing the problem of fragmentation in care, are using the team approach for other conditions.
To be most effective, superdoctor teams need to work together on a regular basis. If you were to throw together several sports players—even professional athletes—to play as a team without training together, they would not play as well as they would with team members who they were used to. Similarly, medical teams must "practice" together to fully leverage their collective ability.
We can take clues for the formation of superdoctor teams from the types of cases that currently require many specialist appointments—teams should be formed that can handle these cases together more effectively than the specialists could working separately. The advantage of the team is not just the ability to do what the individual specialists would do separately; it's the ability to treat a wide range of conditions effectively, to make very subtle distinctions that are important for effective care, to solve the cases that are the most difficult due to the interplay of multiple causes or complications.
The capabilities of superdoctor teams will grow through being challenged, and they will learn from experience. Innovation in their composition and testing their abilities is key. We can only discover their effectiveness through observing how they respond to challenges. Measuring their effectiveness brings us back to Step II.
Superdoctor teams can assume the dynamics we described in Step II: Empower Workgroup Competition, competing against one another and continuously pushing the boundaries to improve care and reduce costs. By measuring their performance, we can learn how to build more and more effective teams, both in terms of choosing types of specialists to be on a team and in their specific interactions.
It is important to note that, in trying to stem the cost of specialist care, alternative cost-cutting approaches have been tried but have not been successful.
Some have proposed having primary care physicians treat more cases, to reduce the number of specialists that patients see as a way of reducing healthcare costs. This approach, though at times politically popular, is ineffective. Family physicians can treat a certain set of conditions, but they do not have the specific knowledge to treat many complex, more specialized conditions.
Of course, we will still need primary care physicians—many problems are best treated by a single person knowledgeable about a wide range of conditions. We also will continue to benefit from individual specialists, or from specialists who don’t normally work together collaborating for particular patients. This works fine for problems of intermediate complexity.
However, for the increasing number of highly complex cases, superdoctor teams are necessary for comprehensive, integrated, cost-effective, quality care.
We must take steps to form innovative specialist teams that can treat the most complex cases successfully and cost-effectively. Introducing such teams is essential if we are to put our vast medical knowledge to effective use.
For further reading
1. Multidisciplinary team members. Medical Univerity of South Carolina, Hollings Cancer Center.
2. Why coordinated care. Cleveland Clinic, Neurological Institute.
3. K. Calman, D. Hine, A policy framework for commissioning cancer services: A report by the expert advisory group on cancer to the chief medical officers of England and Wales. (Department of Health, London, 1995)
4. A. Fleissig, V. Jenkins, S. Catt, L. Fallowﬁeld, Multidisciplinary teams in cancer care: are they effective in the UK? Lancet Oncology 7, 935–43 (2006)
5. J. H. Chang, E. Vines, H. Bertsch, D. L. Fraker, B. J. Czerniecki, E. F. Rosato, T. Lawton, E. F. Conant, S. G. Orel, L. Schuchter, K. R. Fox, N. Zieber, J. H. Glick, L. J. Solin, The impact of a multidisciplinary breast cancer center on recommendations for patient management. Cancer 91, 1231-1237 (2001).
6. R. A. Hayward, The Calman–Hine report: a personal retrospective on the UK’s ﬁrst comprehensive policy on cancer services. Lancet Oncology, 7, 336−346 (2006).
7. J. Hearn, I. J. Higginson, Do specialist palliative care teams improve outcomes for cancer patients? A systematic literature review. Palliative Medicine, 12, 317-332 (1998).
8. D. Burke, H. Herrman, M. Evans, A. Cockram, T. Trauer, Educational aims and objectives for working in multidisciplinary teams. Australasian Psychiatry, 8, 336-339 (2000)
9. M. A. Denvir, J. P. Pell, A. J. Lee, J. Rysdale, R. J. Prescott, H. Eteiba, A. Walker, P. Mankad and I. R. Starkey, Variations in clinical decision-making between cardiologists and cardiac surgeons; a case for management by multidisciplinary teams? Journal of Cardiothoracic Surgery, 1, 2 (2006).
10. K. Gottlieb, I. Sylvester, D. Eby, Transforming your practice: what matters most. American Academy of Family Physicians, Family Practice Management, 2008.
11. Healthcare Transformation. PowerPoint presentation, Southcentral Foundation, Alaska Native Medical Center, Institute for Healthcare Improvement, 2006.
12. L. R. Harrold, T. S. Field, J. H. Gurwitz, Knowledge, patterns of care, and outcomes of care for generalists and specialists. Journal of General Internal Medicine, 14, 499-511 (1999).
13. B. Starfield, L. Shi, J. Macinko, Contribution of primary care to health systems and health. Milbank Quarterly, 83, 457-502 (2005).
14. V. E. Stone, F. F. Mansourati, R. M. Poses, K. H. Mayer, Relation of physician specialty and HIV/AIDS experience to choice of guideline-recommended antiretroviral therapy. Journal of General Internal Medicine, 16, 360-368 (2001).
15. A. Fendrick, R. Hirth, M. Chernew, Differences between generalist and specialist physicians regarding Helicobacter pylori and peptic ulcer disease. American Journal of Gastroenterology 91, 1544–1548 (1996).
Writing and Editing Credits
Yaneer Bar-Yam with Shlomiya Bar-Yam, Karla Z. Bertrand, and Nancy Cohen
Pages 1-3: Diagrams by Alexander S. Gard-Murray and Yaneer Bar-Yam
Page 4: "Portrait of happy doctors standing together" © iStockphoto / Daniel Laflor
Alexander S. Gard-Murray